Rapidly progressive glomerulonephritis other diagnostic studies: Difference between revisions
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* The hallmark histologic lesions in most of the studies of acute pauci-immune ANCA positive as well as ANCA negative glomerulonephritis are documented as | |||
* crescents and fibrinoid tuft necrosis, | |||
* which occur at the same frequency irrespective of the presence or absence of associated systemic vasculitis [3,6,7] . | |||
* in microscopic polyangitis and Wegener’s granulomatosis observed necrotizing crescentic glomerulonephritis as the commonest histopathological diagnosis followed by crescentic glomerulonephritis without fibrinoid necrosis (23%), as the next most common histological diagnosis in patients with ANCA positive serology which almost corresponds to the work conducted by researchers in the western hemisphere. [8] | |||
* In the present study however, of all the ANCA positive cases on histology, the maximum number of cases were of ESRD accounting for 26.66% of cases. Focal and segmental mesangial proliferative and crescentic glomerulonephritis without fibrinoid necrosis were the next most common category (20.00%) followed by necrotizing crescentic glomerulonephritis (13.33%). Necrotizing glomerulonephritis, focal proliferative and membranous with foci of fibrinoid necrosis were the next most common category having 1 case each (6.66%). Thus in contrast to the documented finding of most common histological findings of cresenteric type glomerulonephritis in cases of systemic vasculitis by various researchers, diffuse global glomerulosclerosis/ ESRD was the most common histological finding in our group. The fact this was also the most common histological diagnosis in ANCA negative sub-group also speaks volume about the delayed presentation and patient ignorance as a great challenge to nephrologists in developing countries of Asia and Africa. | |||
* Of the 30 parameters under which every renal biopsy (120) in the present study was scored as detailed in materials and methods; the most common parameters observed in ANCA positive biopsies were- fibrinoid necrosis, glomerular loop neutrophil infiltration, interstitial oedema and arterial hyalinization (all seen in 80% ANCA positive renal biopsies). Tubular changes in the form of atrophy and presence of casts and glomerular sclerosis (73.33%) were the next most common changes followed by peri-glomerular infiltrate along with myointimal hyperplasia accounted for 66.66%. On the other hand in ANCA negative non-pauciimmune glomerulonephritis cases the most common histological parameters were tubular casts (72.38%) followed by interstitial fibrosis (51.42%). Glomerular basement membrane thickening and arterial hyalinization (48.57%) and tubular atrophy and focal interstitial infiltration (44.76% in each) were other significant histological findings [Table/Fig-3]. | |||
== Glomerular Changes == | |||
* Of the ANCA positive biopsies crescents were noted in all the cases with fibrocellular being the commonest (40 %) followed equally by cellular and fibrous crescents (26.66%). Fibrinoid necrosis of the glomerular tuft was seen in 80% of the glomeruli. In 46.66% of cases there was neutrophilic infiltration of the glomerular capillary loops [Table/Fig-3,,66]. | |||
* Other studies such as EUVAS study have shown that 45% of glomeruli had (predominantly cellular) crescents and 23% were globally sclerotic. Fibrinoid necrosis of the glomerular tuft was seen in 22% of the glomeruli [8] . In 5% of cases the fibrinoid necrosis was present with out crescents [Table/Fig-6]. In a study of 32 renal biopsies from patients with microscopic polyangiitis, Savage et al., identified glomerular segmental necrosis in 100 % and crescent formation in 88 % [9] but in another study of 20 renal biopsies by D'Agati a year later in patients of microscopic polyangitis only 80% had segmental glomerularnecrosis and 85% had crescents [10] . In comparison to ANCA positive biopsies; crescents noted in ANCA negative biopsies were mainly fibrous (16.6%) followed by fibro-cellular (3.80%) and cellular (1.90%). Other glomerular changes seen in this subset of biopsies were increased glomerular basement membrane thickening (48.57%), glomerulosclerosis (41.90%) and increased mesangial proliferation (45.71%) [Table/Fig-3]. interstitial edema | |||
* focal tubular epithelial flattening as the most common findings seen in tubules of pauci-immune glomerulonephritis. | |||
* In interstitium; interstitial infiltration by leukocytes is common and is most pronounced adjacent to severely inflamed glomeruli or vessels. | |||
* interstitial oedema was seen in 80% of ANCA positive biopsies and interstitial infiltrate was seen either focally or in diffuse fashion. | |||
* In both cases mononuclear infiltrate formed the predominant part (86.66%), of the infiltrate of ANCA positive cases followed by neutrophils and eosinophils in 26.66% and 20.00% cases respectively. Interstitial fibrosis was present in 60% of ANCA positive biopsies in this study. Many studies such as the one conducted by Haeur et al., have also noted the presence of interstitial oedema but only in 34% of biopsies along with interstitial infiltrates (predominantly mononuclear) in 92% of biopsies and fibrosis was present in 83% of biopsies. | |||
* In contrast to above findings; in ANCA negative biopsies the statistically different parameters were interstitial oedema (36.19%) and interstitial eosinophilic infiltrate. | |||
* Although tubular casts were seen in almost same frequency in both ANCA positive and negative biopsies (73.37% & 72.38%); tubular necrosis, atrophy and tubulitis were noted more in ANCA positive biopsies in comparison to ANCA negative biopsies. | |||
==References== | ==References== | ||
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- The hallmark histologic lesions in most of the studies of acute pauci-immune ANCA positive as well as ANCA negative glomerulonephritis are documented as
- crescents and fibrinoid tuft necrosis,
- which occur at the same frequency irrespective of the presence or absence of associated systemic vasculitis [3,6,7] .
- in microscopic polyangitis and Wegener’s granulomatosis observed necrotizing crescentic glomerulonephritis as the commonest histopathological diagnosis followed by crescentic glomerulonephritis without fibrinoid necrosis (23%), as the next most common histological diagnosis in patients with ANCA positive serology which almost corresponds to the work conducted by researchers in the western hemisphere. [8]
- In the present study however, of all the ANCA positive cases on histology, the maximum number of cases were of ESRD accounting for 26.66% of cases. Focal and segmental mesangial proliferative and crescentic glomerulonephritis without fibrinoid necrosis were the next most common category (20.00%) followed by necrotizing crescentic glomerulonephritis (13.33%). Necrotizing glomerulonephritis, focal proliferative and membranous with foci of fibrinoid necrosis were the next most common category having 1 case each (6.66%). Thus in contrast to the documented finding of most common histological findings of cresenteric type glomerulonephritis in cases of systemic vasculitis by various researchers, diffuse global glomerulosclerosis/ ESRD was the most common histological finding in our group. The fact this was also the most common histological diagnosis in ANCA negative sub-group also speaks volume about the delayed presentation and patient ignorance as a great challenge to nephrologists in developing countries of Asia and Africa.
- Of the 30 parameters under which every renal biopsy (120) in the present study was scored as detailed in materials and methods; the most common parameters observed in ANCA positive biopsies were- fibrinoid necrosis, glomerular loop neutrophil infiltration, interstitial oedema and arterial hyalinization (all seen in 80% ANCA positive renal biopsies). Tubular changes in the form of atrophy and presence of casts and glomerular sclerosis (73.33%) were the next most common changes followed by peri-glomerular infiltrate along with myointimal hyperplasia accounted for 66.66%. On the other hand in ANCA negative non-pauciimmune glomerulonephritis cases the most common histological parameters were tubular casts (72.38%) followed by interstitial fibrosis (51.42%). Glomerular basement membrane thickening and arterial hyalinization (48.57%) and tubular atrophy and focal interstitial infiltration (44.76% in each) were other significant histological findings [Table/Fig-3].
Glomerular Changes
- Of the ANCA positive biopsies crescents were noted in all the cases with fibrocellular being the commonest (40 %) followed equally by cellular and fibrous crescents (26.66%). Fibrinoid necrosis of the glomerular tuft was seen in 80% of the glomeruli. In 46.66% of cases there was neutrophilic infiltration of the glomerular capillary loops [Table/Fig-3,,66].
- Other studies such as EUVAS study have shown that 45% of glomeruli had (predominantly cellular) crescents and 23% were globally sclerotic. Fibrinoid necrosis of the glomerular tuft was seen in 22% of the glomeruli [8] . In 5% of cases the fibrinoid necrosis was present with out crescents [Table/Fig-6]. In a study of 32 renal biopsies from patients with microscopic polyangiitis, Savage et al., identified glomerular segmental necrosis in 100 % and crescent formation in 88 % [9] but in another study of 20 renal biopsies by D'Agati a year later in patients of microscopic polyangitis only 80% had segmental glomerularnecrosis and 85% had crescents [10] . In comparison to ANCA positive biopsies; crescents noted in ANCA negative biopsies were mainly fibrous (16.6%) followed by fibro-cellular (3.80%) and cellular (1.90%). Other glomerular changes seen in this subset of biopsies were increased glomerular basement membrane thickening (48.57%), glomerulosclerosis (41.90%) and increased mesangial proliferation (45.71%) [Table/Fig-3]. interstitial edema
- focal tubular epithelial flattening as the most common findings seen in tubules of pauci-immune glomerulonephritis.
- In interstitium; interstitial infiltration by leukocytes is common and is most pronounced adjacent to severely inflamed glomeruli or vessels.
- interstitial oedema was seen in 80% of ANCA positive biopsies and interstitial infiltrate was seen either focally or in diffuse fashion.
- In both cases mononuclear infiltrate formed the predominant part (86.66%), of the infiltrate of ANCA positive cases followed by neutrophils and eosinophils in 26.66% and 20.00% cases respectively. Interstitial fibrosis was present in 60% of ANCA positive biopsies in this study. Many studies such as the one conducted by Haeur et al., have also noted the presence of interstitial oedema but only in 34% of biopsies along with interstitial infiltrates (predominantly mononuclear) in 92% of biopsies and fibrosis was present in 83% of biopsies.
- In contrast to above findings; in ANCA negative biopsies the statistically different parameters were interstitial oedema (36.19%) and interstitial eosinophilic infiltrate.
- Although tubular casts were seen in almost same frequency in both ANCA positive and negative biopsies (73.37% & 72.38%); tubular necrosis, atrophy and tubulitis were noted more in ANCA positive biopsies in comparison to ANCA negative biopsies.